下腔静脉造影在肾癌伴发下腔静脉癌栓切除术前评估中的应用价值

The application value of inferior vena cava venography in evaluating renal cell carcinoma associated with inferior vena cava tumor thrombus before surgical resection

目的评价下腔静脉DSA造影检查在肾癌伴发下腔静脉癌栓切除术前评估中的应用价值。方法回顾性分析2017年5月至2019年1月在解放军总医院接受下腔静脉造影检查的连续97例患者,最终纳入共37例肾癌伴发下腔静脉癌栓手术治疗患者。2名具有5年以上临床经验的主治医师分别对下腔静脉造影图像及术前影像进行评价,根据评价标准,下腔静脉完全阻塞且主要侧支循环通路完善、主要侧支循环直径≥10 mm为侧支循环完善组,否则为侧支循环不完善组。分别记录两组患者手术方案选择。两组临床资料作差异性分析,计量指标根据正态分布与否用t检验或MannWhitney秩和检验,计数指标用Fisher确切概率检验。采用Kappa系数分析2名观察者间评价一致性。结果CT、MR显示肾癌伴发下腔静脉瘤栓阻塞程度、侧支循环均有一定限度,下腔静脉造影能清晰显示下腔静脉瘤栓阻塞程度和侧支循环开放情况。37例患者中侧支循环完善组26例,其中14例(53.8%)行机器人辅助腹腔镜肾根治性切除+下腔静脉瘤栓离断术,12例(46.2%)行机器人辅助腹腔镜肾根治性切除+下腔静脉取栓术;侧支循环不完善组11例,全部(100%)行机器人辅助腹腔镜肾根治性切除+下腔静脉取栓术。2名观察者间评价具高度一致性(Kappa=0.871)。两组间患者性别、Mayo分级、术中出血量差异有统计学意义,其余变量差异无统计学意义。结论下腔静脉造影能准确判定肾癌伴发下腔静脉癌栓患者下腔静脉癌栓阻塞程度和侧支循环建立情况,对下腔静脉离断术或取栓术术式选择具有重要指导意义。

Objective To discuss the clinical application of preoperative inferior vena cava(IVC)venography in evaluating renal cell carcinoma associated with IVC tumor thrombus.Methods A total of 97 consecutive patients,who received IVC venography during the period from May 2017 to January 2019 at the Chinese PLA General Hospital,were collected,and 37 patients among them suffered from renal cell carcinoma associated with IVC tumor thrombus and underwent surgical resection.Their images of IVC venography and preoperative imaging were separately evaluated by two physicians with more than 5 years of clinical experience.The patients having completely blocked IVC,perfect collateral circulation pathway and the diameter of main collateral vessels≥10 mm were classified as the perfect collateral circulation group(n=26),otherwise the patients were classified as imperfect collateral circulation group(n=11).The surgical scheme of the two groups was recorded separately.The difference of the clinical data between the two groups was analyzed.According to whether the obtained data had a normal distribution or not,t-test or Mann-Whitney rank sum test was used to analyze measurement indexes,while Fisher exact probability was adopted to test counting indexes.Kappa coefficient was used to analyze the consistency of two physicians’results.Results The role of CT and MRI in displaying renal cell carcinoma,IVC obstruction due to tumor thrombus and collateral circulation was limited,while IVC venography could clearly demonstrate the degree of IVC obstruction by tumor thrombus as well as the patency status of collateral circulation.Of the 26 patients of perfect collateral circulation group,robot-assisted laparoscopic radical nephrectomy plus transection of IVC tumor thrombus was employed in 14(53.8%)and robot-assisted laparoscopic radical nephrectomy plus IVC thrombectomy was performed in 12(46.2%).All the 11 patients of imperfect collateral circulation group received robot-assisted laparoscopic radical nephrectomy plus IVC thrombectomy.The evaluation of the two physicians was highly consistent(Kappa=0.871).The differences in gender,Mayo classification and intraoper-ative amount of bleeding between the two groups were statistically significant,and no statistically significant differences in other variables existed between the two groups.Conclusion IVC venography can accurately display the degree of IVC obstruction by tumor thrombus and the patency status of collateral circulation in patients with renal cell carcinoma complicated by IVC tumor thrombus,which is of great significance for the selection of IVC transection or IVC thrombectomy.